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Many acutely ill children are not fully conscious. Most make a full neurological recovery as the underlying cause is treated, but considerable skill is required to distinguish the group at high risk of further deterioration, potentially leading either to death or to severe handicap. This article is an attempt to guide the worried paediatrician in casualty or on the ward faced with a child in non-traumatic coma who may need intensive care. The most effective method of deciding the order of priorities in this emergency situation is to ask oneself a series of questions.
Is the child unconscious and if so, how deeply?
This is the most important question of all and may well be the most difficult to answer. The Glasgow Coma Scale was designed to assess depth of coma after head injury in adults and has been used in paediatric non-traumatic coma.1-3 Although alternatives such as the Seshia scale have less interobserver variability, probably because there are fewer choices,4 the Glasgow scale is very familiar to nursing staff and casualty officers and works well down to the age of 5. In those below that age, the motor and eye opening scales may be used (except that children below the age of 9 months cannot localise pain), but a modification of the verbal scale is needed. The modified James scale (table 1) has been used successfully in several UK centres, can be consistently reproduced between observers,5 and has therefore been endorsed by the British Paediatric Neurology Association. The response to pain should be examined both with a supraocular stimulus (for localisation, flexion, and extension) and with nailbed pressure, for example with a pencil (for withdrawal). There may be a need for flexibility in terms of the overlap between the age groups. Thus, children of any age who are restless and talking unintelligibly have a verbal …
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